CDBG Bus Pass Application – 2011

CDBG BUS PASS APPLICATION
1. All information must be completed on this form or no pass will be issued.
2. You must submit a copy of a government issued photo ID (I.e., driver's license, military ID, Passport).
3. Your bus pass will be mailed to you at the address you list. You are responsible to notify the CART office of any change in your
contact information.
4. You must have a residential address in the Norman city limits. Passes will not be mailed to P.O. Box or business addresses.
5. In signing this form, you understand that you are making specific statements about your household and income level that are
required for the federal funding utilized for this bus pass program.
6. You also understand that false statements will result in a loss of all bus pass privileges and may result in legal action.
7. This project is based on income eligibility only. Household information and racial characteristics will not be used to determine
eligibility.
8. This form must be completed for each person requesting a bus pass. Parents/Guardians may fill out an application for each youth
under the age of 18.
9. Applications are good from July 1 through June 30 of the following year. A new application must be completed annually.
Please use black ink to answer the following questions and print clearly:
Name:-------------------- Applicant's Date of Birth:----------
Street Address:-------------------- Apt.#:-------------
City:------------- State: __________ Zip:-----------
A. How many people are there in your family household at this address?
B. What was last year's total gross income for the family household living at this address? -------
C. Are you a CART access van user (origin-to-destination service for the disabled)?
D. For each person on your household, please supply the following information listing your information first:
American
Black/ African Indian/ Native Hawaiian/ Balance/ Ethnicity
Age Sex White American Asian Native Alaskan other Pacific Islander Other is Hispanic?
Applicant l---+-----t----ll-----+----t-------l-------+-----1-----l
Others in Household l---+-----t----ll-----+----l-------l-------+-----1-----l
Others in Household l---+-----+---l-----t----t------4-------+----4-----l
Others in Household
Others in Household
Others in Household
Others in Household
Others in Household
Signature "I have read and understand the above. All answers provided are true." Date
OFFICE USE ONLY
ID# ________________ _ 10 Type _______ __
Agency Representative
Agency Phone Number (405) --------------------
Revised 4/1/11

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CDBG BUS PASS APPLICATION
1. All information must be completed on this form or no pass will be issued.
2. You must submit a copy of a government issued photo ID (I.e., driver's license, military ID, Passport).
3. Your bus pass will be mailed to you at the address you list. You are responsible to notify the CART office of any change in your
contact information.
4. You must have a residential address in the Norman city limits. Passes will not be mailed to P.O. Box or business addresses.
5. In signing this form, you understand that you are making specific statements about your household and income level that are
required for the federal funding utilized for this bus pass program.
6. You also understand that false statements will result in a loss of all bus pass privileges and may result in legal action.
7. This project is based on income eligibility only. Household information and racial characteristics will not be used to determine
eligibility.
8. This form must be completed for each person requesting a bus pass. Parents/Guardians may fill out an application for each youth
under the age of 18.
9. Applications are good from July 1 through June 30 of the following year. A new application must be completed annually.
Please use black ink to answer the following questions and print clearly:
Name:-------------------- Applicant's Date of Birth:----------
Street Address:-------------------- Apt.#:-------------
City:------------- State: __________ Zip:-----------
A. How many people are there in your family household at this address?
B. What was last year's total gross income for the family household living at this address? -------
C. Are you a CART access van user (origin-to-destination service for the disabled)?
D. For each person on your household, please supply the following information listing your information first:
American
Black/ African Indian/ Native Hawaiian/ Balance/ Ethnicity
Age Sex White American Asian Native Alaskan other Pacific Islander Other is Hispanic?
Applicant l---+-----t----ll-----+----t-------l-------+-----1-----l
Others in Household l---+-----t----ll-----+----l-------l-------+-----1-----l
Others in Household l---+-----+---l-----t----t------4-------+----4-----l
Others in Household
Others in Household
Others in Household
Others in Household
Others in Household
Signature "I have read and understand the above. All answers provided are true." Date
OFFICE USE ONLY
ID# ________________ _ 10 Type _______ __
Agency Representative
Agency Phone Number (405) --------------------
Revised 4/1/11